Astana Medical University

Author: Riza Nurpeissova

Case outline

You are a general practitioner  in outpatient department. Your new patient is a 68 year old man, Serik Baizhanov. You are a GP doctor in the outpatient department, the patient Serik Baizhanov came to you, 68 years old, complained of a fever of 39.5C, a cough with hard-to-recover sputum, a headache, dizziness, general weakness, shortness of breath and palpitations, and chest pains.

Anamnesis of the disease: According to patient's  information: he is sick within a week when appeared the increase of the temperature to 39.0 C, a cough with hardly detachable sputum, the patient connects with hypothermia. Independently he was treated at home: plentiful drink, teraflju, ambro, salbutamol, bisoprolol. According to the daughter's words his condition went worse today, when the cough increased, joined dyspnea, body temperature rose to 39.5 C, chest pain.

Additional information from patient history: Three years ago, there was an operation on the heart; the patient does not remember the name of the surgical intervention, he is on a dispensary record with a cardiologist, the diagnosis: Ischemic heart disease, angina pectoris,  the second  functional class (due to classification). Harmful habits: smokes for 35 years, deep vein thrombosis of the leg.

Additional information from patient history:Physical  examination of patient:Additional information from patient history: The patient is Baizhanov Serik, 68 years old: when examined, the skin is pale, moist, breathing is hard in the lungs, breathing is weak in the lower sections, and wheezing is heard there. Heart rate 85 per minute, breathing rate  23 per minute, BP 140/80. Heart tones are muffled, the rhythm is correct.

Choice 1 take a general blood test/send to a pulmonologist: Results of blood test: hemoglobin 95 g  red blood cells 4.5 X10.9 / l, leukocytes 19.8 X10.9 / l, neutrophils 89%, monocytes 1%, eosinophils 5%, lymphocytes 15%

Choice 2 give an antibiotic and send the patient home: You are a GP doctor, prescribe amoxicillin 1gr antibiotics 3 times a day orally for 7 days, followed by examination in outpatient department. Serik thanks you for your help and goes home. You received a call from the hospital, and were told that Serik Bayzhanov was urgently hospitalized.

Choice 3  do a chest x-ray, do re-examination: The patient is Baizhanov Serik, 68 years old: when examined, the skin is pale, moist, breathing is fast, in the lungs, breathing is weak in the lower sections, and wheezing is heard there. Heart rate 85 per minute, respiratory 23 per minute, BP 140/80. Heart tones are muffled, the rhythm is correct. A chest x-ray was performed.

Learning  outcome for VP case

• Clinical manifestations of pneumonia,
• Peculiarities  in elderly patients,  treatment, specific investigations,
• Clinical signs  of infection toxic shock, differential diagnosis of cough, according to  national guidelines.

Medical error:

• Poor triage
• Fixation
• Ignorance
• Poor communications and bravado

Author: Zhanna Bekbergenova

Case outline

You are a resident doctor. Your patient: Alma, a teacher of 60 years

You are a resident doctor, practice at the GP department in the city polyclinic No. 4. Because of the absence of a doctor on the site, you were sent to a call to the patient’s house. Patient Alma, a teacher of 60 year. Patient, complains about pains in the occipital region, dizziness, noise in the ears, flashing of flies before his eyes, nausea. Deterioration is associated with emotional stress.

Anamnesis of the disease: The patient is registered with D-accounting for arterial hypertension, basic therapy does not take regularly. From her words she drank a tablet of nifedipine and enalapril 10 mg. before your arrival (about half an hour). You are measuring blood pressure. The blood pressure on the right and left arm is 200/120 mm Hg.

Choice 1 Give a tablet of captopril and recommend sleeping: By giving a captopril pill, you are gone. About an hour later, the patient's condition worsened. The husband called the ambulance brigade and insisted on Alma being hospitalized. You are a resident doctor of the therapeutic department. You stayed overnight, watch the third night in a row. You feel pretty tired. Last night was full of aggressive people intoxicated. Your fellow student resident doctor examines a febrile patient, an urgent doctor was called for consultation in the department. An ambulance brings a woman on a stretcher and enters the emergency room where the nurse registers the patient:

Alma, a 60-year-old teacher, has difficulty speaking, complaining of headaches, dizziness, noise in the head, and nausea. She asks to let her go home as soon as she has a headache. Alma's husband is distressed and tells you that his wife does not like hospitals since her sister died in the same hospital. He tells you that she has panic attacks. You measure blood pressure, which is equal to 220/120 mm Hg.

Choice 2 Observe the patient and give a tablet of nifedipine: You gave a tablet of nifedipine. After the pill, the patient's condition deteriorated, there was a difficulty of speech. When measuring blood pressure about 90/60 mm Hg. Alma's husband began to make trouble. You called an ambulance crew to hospitalize you. You are a resident doctor of the therapeutic department. You stayed overnight, watch the third night in a row. You feel pretty tired. Last night was full of aggressive people intoxicated. Your fellow student resident doctor examines a febrile patient, an urgent doctor was called for consultation in the department. An ambulance brings a woman on a stretcher and enters the emergency room where the nurse registers the patient: Alma, a 60-year-old teacher, has difficulty speaking, complaining of headaches, dizziness, noise in the head, and nausea. She asks to let her go home as soon as she has a headache. Alma's husband is distressed and tells you that his wife does not like hospitals since her sister died in the same hospital. He tells you that she has panic attacks. You measure blood pressure, which is equal to 220/120 mm Hg.

Choice 3 Hospitalize the patient in an urgent way to the hospital: You are a resident doctor of the therapeutic department. You stayed overnight, watch the third night in a row. You feel pretty tired. Last night was full of aggressive people intoxicated. The emergency doctor was called for a consultation at the department. An ambulance doctor brought a woman to the emergency room, where a nurse registers patient Alma.

You have many scandalous and noisy patients in the emergency room. One of the waiting patients entered into an altercation with Alma's husband. The nurse called the guards and tried to calm them down. You are inspecting Alma. Alma, a 60-year-old teacher, complaining of headaches, dizziness, noise in the head and nausea. Alma had difficulty speaking after her husband's altercation. She asks to let her go home as soon as she has a headache. Alma's husband is distressed and tells you that his wife does not like hospitals since her sister died in the same hospital. He tells you that she has panic attacks. You measure blood pressure, which is equal to 220/120 mm Hg.

Learning outcome for VP case

• Definition of hypertension, classification hypertension due to of levels of BP
• Types of headache, differential diagnosis, clinical presentation
• Physical examination, some clinical features
• Laboratory and instrumental check-up
• Hypertension management, patient education, treatment according to local guidelines.

Medical error

• Lack of skill
• Miss-triage
• System error

Author: Аigerim Zhuzzhasarova

Case outline

You are a doctor of an infectious hospital.
You are a doctor of a children's infectious hospital. Three children are admitted to your department simultaneously: 1. Child- Asem, age 5 years. T-37.1C. Complaints about: runny nose, cough, loss of appetite, weakness. 2. Child -Askar, age 2 year T38.5 C. Complaints about: anxiety, shortness of noisy breathing, hoarseness of voice, rough barking cough, shortness of breath. 3. Child Marat, age 7 years. T-36.5C. Complaints about double vomiting, anxiety, lethargy. The liquid drinks well, the appetite is reduced.

Choice 1 Which child most requires attention? Child with subfebrile temperature: You examined Asem, diagnosed At this point, the nurse approached you and said that the child with difficulty breathing became worse and asked you to examine him immediately.

Choice 2 Child with difficult noisy breathing: In the examined child, Askar, the mother notes that the child’s condition is worsening and it is difficult for him to breathe, she is concerned about the condition of the child and asks you to help the child. On examination: Weight 14kg, Height 74 cm, SaO2 87% for oxygen. A child with low weight. Pale skin, clean, pronounced sweating. Turgor tissue and muscle tone satisfactory. Subcutaneous fat layer is developed poorly. Mucous pink moist. Lymph nodes: not enlarged. Throat slight hyperemia. On the part of the musculoskeletal system, there is no pathology. Breathing through the nose is difficult. Respiratory rate 60 per minute. On examination, the wings of the nose swell, as well as participation in the act of breathing of the auxiliary intercostal muscles (retraction of the lower chest wall). Percussion the lungs clear pulmonary sound with a box tint. the child is restless, agitated, occasionally crying, frequent breathing is noisy, audible at a distance, stridor, voice hoarse, rough barking cough, not bringing relief to the child. Perioral cyanosis. Tachycardia while maintaining a rhythmic pulse. T-37.0 C, pressure: 90 / 60mm pt. Art., HR -136, breathing rate - 60 per minute.

Choice 3 Child with a single vomiting: You have examined the child Marat. Mom says that the child had a single vomiting in the evening, after taking fatty meat. In the morning once again vomiting, but less in quantity. Mom is worried and does not understand why the child has repeated vomiting. You explain to your mother that these are dyspeptic disorders of the stomach, due to non-penetrating fatty foods. Assign treatment, enzyme and oral solution. And ask to return if the child becomes worse. At this point, the nurse approached you and said that the child with difficulty breathing became worse and asked you to examine him immediately.

Learning outcome for VP case

• Clinical picture, complications and differential diagnosis of stenosis
• Laboratory diagnostics of laryngotraheitis
• Treatment and prevention of laryngotraheitis

Medical error

• Poor communication
• Ignorance
• Poor triage
• Bravado
• Playing the odds
• System error

Author: Valentina Tyan

Case outline

You are a doctor in the emergency room.

You are a doctor in the emergency room. During your duty Luiza Akhmetova 34 years, is taken by the ambulance brigade. The patient complaints of regular contractions. She was examined by an ambulance doctor who noted the full opening of the uterine throat. From anamnesis: pregnancy - 6, 2 abortions (the last abortion was complicated by metroendometritis), childbirth - 4, miscarriage - 1. 3 minutes after admission, at the reception room, the birth began and a boy was born with a weight of 3250, the score for Apgar was 7-8. The neonatologist was urgently invited to the emergency room. 15 minutes after the birth, a heavy bleeding started, which could not be stopped. The blood loss was 600 ml.

Choice 1 carry out an objective examination and examination of the placenta: The skin and visible mucous membranes are pale pink in color. The tongue is wet. Breathing free, 18 per min. Heart tones are clear, rhythmic, heart rate is 90 beats per minute, Pulse is 90 beats per minute, body temperature is 36.0 * C. The abdomen is soft, enlarged by the uterus. Uterus navel level, flabby. Placenta without a defect: the lobes of the placenta and membranes are intact.

Choice 2 mobilization of free staff: Call for help experienced obstetrician-gynecologist, who owns the operational equipment in full. Call anesthesiologist-resuscitator. Call the technician in the emergency room. Allocate an employee for permanent management of an intensive care card (control of blood pressure, pulse, temperature, respiratory rate).

Choice 3 collect anamnesis and start the administration of oxytocin: Menarche from the age of 13, for 4-5 days, after 28-30 days, regular, moderately painful. Sex life since 20 years, in marriage - 14 years. Tuberculosis, hepatitis, veins. disease denies. Operations, injuries were not. Hemotransfusions were not. Allergic history is calm. Somatically, from the words, healthy. On the D-account is not a specialist. Made: oxytocin 10 u / m. oxytocin 5 units and physiological . solution of 200 ml .

Learning outcome for VP case

• Indications for hospitalization
• Differential diagnosis principles of management features of patients with bleeding
• Complications of bleeding mortality rate

Medical error

• Ignorance
• Team-working
• Playing the odds
• Poor communication
• Bravado

Author: Ksenia Shnaider

Case outline

You are a registra in outpatient department.  Pregnant woman of 20 years came to you, a gestation period of 28 weeks, he is making complaints: fatigue, weakness, dizziness, daytime drowsiness and sleeplessness at night, decreased performance, irritability, tearfulness.

Patient history: previous conditions: last flu, a chronic pyelonephritis, menarche from 13 years, 1 marriage, pregnancy - 2, no allergy, without bad habits. There was no contact with infectious patients. There were no blood transfusions. Injuries, surgeries denied.

Physical examination: Skin pale, light yellowness of the hands and nasolabial triangle. Consciousness is clear. Temperature: 37.0. The heart rate is 78-88 beats / min, the BP 90/60 mm Hg on the left arm and 90/60 mm Hg on the right arm, with auscultation of the heart - systolic murmur at the apex of the heart and at the point of the projection of the pulmonary artery, the deafness of the heart sounds. There is shortness of breath during physical activity, auscultation - there are no changes in lungs. The abdomen is soft, increased due to pregnancy. A uterus with clear contours, tone is elevated, there are no local pains. The position of the fetus is longitudinal, there is a head. Palpitation of the fetus 140 beats per minute, rhythmic.

Choice 1 Consultation of the gynecologist

• Ask the patient to come to the survey in the clinic
• Let go home, recommend to get registered for pregnancy
• Consultation of the gynecologist

Choice 2 Hospitalize immediately

• Hospitalize immediately
• Hematologist's consultation
• To give direction on blood biochemistry, urinalysis

Choice 3 Blood transfusion

• Assign parenteral administration of iron preparations
• Assign iron supplements per os
• Perform blood transfusion

Choice 4 Supervision in female consultation with obligatory intake of iron preparation

• Supervision in female consultation with obligatory intake of iron preparations
• Write out and recommend to get registered for pregnancy
• Take iron supplements at home

Learning outcome for VP case

Deepening and expanding knowledge of the causes of anemia during pregnancy. Development of the ability to assess and analyze the situation with the development of anemia in pregnant women. Skills and skills in choosing tactics, diagnosis, emergency care, rational transportation and post-hospital rehabilitation in anemia in pregnant women at the primary level.

To successfully solve this case, the student must carry out differential diagnosis and determine the most likely causes of anemia during pregnancy.

List diagnostic methods, draw up and justify a survey plan at the primary and hospital level.

Justify the need for consultations of narrow specialists, hospitalizations and the profile of the medical institution.

Determine the degree of need for follow-up (drug and non-drug treatment)

Medical error

• Playing the odds
• Poor triage
• Fixation

Author: Meruert Zhakupbekova

Case outline

You are a doctor in the hospital. Your new patient is Marchenko Dmitry, 19 years old.

He enters the emergency room at 22.00 arrives by ambulance with complaints of abdominal pain, nausea, repeated vomiting.

Anamnesis of the disease: You find out that the pains in the abdomen appeared for the first time. Dmitry celebrated his birthday with friends, where he drank two bottles of Dizi. This deterioration is associated with the reception of energy drink Dizi. He enters the emergency room at 22.00 arrives by ambulance with complaints of abdominal pain, nausea, repeated vomiting. Among friends, no such symptoms were present.

Additional information from patient history: The patient is registered for chronic gastritis, irregularly eats, mostly in dry bread, as he spends the whole day at the university. At the poll it was found out that the patient drinks liquids in volume of 1.5-2 liters per day.

Physical examination of patient: Objectively: The patient is somewhat drowsy, answers questions with a hitch. The skin is pale, dry to the touch. Height 170, weight 64 kg BMI = 22 kg / m2. In the lungs, breath is vesicular, there is no wheezing. BH 20 per min. Heart rhythmic activity, clear tones, blood pressure 100/80 mmHg, HRC 116 per min. The abdomen is soft, painful in epigastrium. The liver is palpated at the edge of the costal arch.

The patient arrived accompanied by his mother.

Choice 1 Make a UAC-triad and call for a surgeon's consultation: Hv-161 g / l, erythr.-3.8, leukocytes- whole day at the university. The survey revealed that the patient drinks liquids in a volume of 1.5-2 16.9 * 109 / l, platelets 318 * 109 / l, ESR-3 mm / h. They called for a consultation with the surgeon: when viewed, the surgeon during palpation determines the pain in the epigastrium, eliminates signs of acute abdomen and prescribes EGDS.

Choice 2 rinse the stomach and send the patient home: You wash the stomach to clean water. As well as rehydration therapy with isotonic solution, taking into account the loss of fluid during vomiting. Wash water sent to the bak.posev. The condition after the performed procedures has slightly improved. You give recommendations for treatment and send Dmitry home with the subsequent treatment in a polyclinic.

Choice 3 EGDS and hospitalized in the therapeutic department: EGDS :The esophagus is freely passable, the mucous is whitish-pink, with several uneven relief. Folds thickened, with insufflation straightened. Peristalsis is active. Cardia closes completely. In the cavity of the stomach is a moderate amount of light mucus. The folds of the cardia and the body are enlarged. Uneven. The relief of the mucous is emphasized due to moderate diffuse hyperplasia. The surface is dull. In the cardia and the proximal part of the body of the stomach, there is a small-focal hyperemia of a pronounced nature. In the antrum, the mucous is flat, the folds are completely unfolded. The gatekeeper closes, we pass. The lumen of the duodenal bulb of the correct form, easily straightened. Mucosa pink, velvety, with a few small foci of moderate hyperemia.

Choice 4 Additional collection of anamnesis of the disease: When interviewing a patient, you find out that the pain in the abdomen appeared for the first time. The day before, he and his friends celebrated his birthday, the patient developed nausea, repeated vomiting, then pain in the abdomen joined. The patient has chronic gastritis, irregularly eats, mainly in the dry nut. Since he spends the liters per day. This deterioration is associated with the reception of the energy drink Dizy. Among friends no one had such symptoms.

Learning outcome for VP case

• Clinical manifestations of diabetes mellitus and its complications.
• Diagnosis and differential diagnosis of diabetes mellitus according to protocol
• Laboratory diagnosis of diabetes mellitus.
• Risk of death from diabetes mellitus
• Treatment of type 1 diabetes mellitus. Therapeutic tactics of managing patients with ketoacidosis according to the protocol.

Medical error

• Ignorance
• Team-working
• Poor communication
• Bravada
• Sloth
• Fixation
• Lack of skills and knowledge